Part 18 (1/2)
Intensity and frequency of movement, duration and deformity of att.i.tude, all alike may vary in the same individual at differing times. Solitude, tranquillity, and repose favour the diminution and even the entire disappearance of spasmodic movements which fatigue, anxiety, and emotion are p.r.o.ne to exaggerate. An instructive case in point is one of van Gehuchten's,[96] the subject being a labourer twenty-five years old, in whom a tic of the right arm and right sternomastoid of seven years'
continuance disappeared whenever the patient was by himself, to burst out afresh as soon as he was conscious of being observed.
Distraction is a valuable sedative. A patient of ours used to pa.s.s the day in twisting his head round with ever-increasing violence, while at night, amid the smiling gaiety of the theatre, hours slipped by without his betraying the least suspicion of his malady.
Occupation, on the other hand, may provoke the condition. d.u.c.h.enne has a reference to a case where rotation of the head to the right commenced whenever the subject started to read, and ceased only with the laying down of the book. In one of our cases the head kept turning whenever and as long as the two hands were simultaneously engaged in some pursuit. If one hand was disengaged, there was no torticollis.
As a general rule, excitement invites or increases movement, whereas sleep frustrates it, and after a good night's rest several minutes or even an hour or two may elapse ere the convulsions rea.s.sert themselves.
Acute pain is rarely met with in the disease we are considering, but sensations of discomfort, of tension, of strain in the muscles, form a common subject of complaint.
By way of example may be cited the case of one of our patients:
L. is eighteen years old, and has been suffering from torticollis for the last six weeks. The chief movement is abrupt rotation and very slight inclination of the head to the right, and the muscles princ.i.p.ally concerned are the left sternomastoid and the right splenius. The head is sunk between the shoulders, of which the right one is elevated synchronously with the rotation, and remains so as long as the latter persists.
The displacement is effected by a moderately brisk muscular contraction that rotates the head to the right on its vertical axis, and succeeding contractions only serve to accentuate the deviation or to maintain it when the head is beginning to revert to its original position. There are none of those upward or downward oscillations, those hesitating, tentative little jerks that some patients make before a.s.suming a fixed torticollis att.i.tude. In L.'s case the duration of the wryneck is exceedingly variable; sometimes the head returns spontaneously to its place, and deviates afresh immediately after, but its periodicity changes with the days, and even with the minutes.
The torticollis is accompanied by a rather disagreeable sensation, a feeling of fatigue in the muscles concerned, of ”dragging” in their bellies as well as at their insertions. The site of this sensation is over the left sternomastoid, on the right half of the posterior aspect of the neck, and deep in the right shoulder, whereas the upper parts of the trapezii, the left half of the neck and its anterior surface, and the right sternomastoid, are areas that are free from pain.
Here, further, as in all cases of the same nature, the subjective sensations differ from day to day, and moment to moment. It is just as perplexing to localise these pains exactly as to fix the topoalgia of a neurasthenic. The lack of precision of the answers is no doubt explicable by the variability of the muscular contractions.
Emotion, apprehension, the presence of strangers, tend to intensify the spasm, which tranquillity and rest will attenuate. On the other hand, the most trivial incident--a sudden noise, an unexpected question, the act of swallowing saliva, of putting out the tongue, etc.--will reawaken the latent torticollis; any surprise, any movement, or even the idea of a movement, suffices for its ebullition.
Under the influence of the will, particularly after a time of rest, the head may sometimes reoccupy the mid position spontaneously, a result unfailingly obtained by distraction also, as when the patient is hearkening thoughtfully to her father's conversation. On her ”bad days,” however, the use of even considerable force fails alike to hinder the head's turning and to effect its replacement.
That is to say, the resistance offered by the torticollis to reduction may at one moment be nil, at another, feeble, or forcible, or even insuperable.
Some patients affected with mental torticollis seem to have lost the sense of position of their head, others evince a want of precision and a.s.surance in the execution of different limb movements. Speaking generally, it may be said that downward movements of the arms are less good than upward ones, and that their synchronous and symmetrical action is accomplished with greater ease than is the operation of one only.
The debut of mental torticollis is usually insidious. Whether head or shoulder be implicated first, the incipient motor reaction is infrequent, inconsiderable, and transitory. Little by little its frequency increases and its duration lengthens, till the end of a few months sees the torticollis established.
It may happen that the onset is so stealthy that it eludes the subject's own notice, and attention is called to his peculiar att.i.tude by the members of his circle. Not seldom the earliest localisation of the condition in a particular muscle is abandoned in favour of some other, and resumed at a subsequent stage. Occasionally the torticollis pa.s.ses from right to left, or vice versa; occasionally, too, the clonic variety may give way to the tonic after a few weeks or months.
It has been already remarked that at the outset the tic is infrequent, and may depend for its manifestation on certain predetermined circ.u.mstances, as, for instance, the exercise of the faculty of writing.
Such was the case with S., with P., and with N.
N. was a patient forty-eight years old, with a left torticollis dating back twenty months. His account of its origin was to the following effect: for some years he had been employed in a commercial office, where from seven in the morning to eight at night he was occupied in writing, head and body being turned to the left. At the beginning of 1900, consequent on a succession of troubles, he noticed that his head was twisting round to the left in an exaggerated fas.h.i.+on while he was writing, and the rotation gradually began to a.s.sert itself at other times, when he was reading, or eating, or b.u.t.toning his boots. Even apart from any other act, the rotatory movement soon became incessant, continuing while he was on his feet, but vanis.h.i.+ng completely if he lay down or if the head was supported. At present he has the greatest difficulty in writing, for his head at once deviates violently to the right.
The spasmodic movements sometimes spread to the shoulder, arm, and trunk, and, in one of our cases, to the leg. Should the condition be advanced, it is frequently complicated by ch.o.r.eiform or athetotic movements in the limbs, or by irregular and arhythmical tremors.
A case of this nature was shown at the Neurological Society of Paris by Marie and Guillain[97]:
The patient, forty-nine years of age, was suffering from muscular spasms that kept turning his head first to one side and then to the other. Fixation of the head between the hands a.s.sured a few moments' respite, but the convulsions were quick to reappear. The left hand was constantly being brought up to the face in the endeavour to procure immobility, while the arms were the seat of abrupt jerking movements intermediate between tremor and ch.o.r.ea.
The various reflexes were normal; stimulation of the sole of the foot evoked a flexor response on either side, and no symptom of hysteria was forthcoming. The disease had made its appearance in 1879, when, without discoverable motive, the head had commenced to tremble and to work round to the left. Section of the tendon of the sternomastoid did not impede the development of the affection, which two years ago increased in intensity, when the above-mentioned movements in the arms were superadded. The likelihood seemed to be that they were of the same nature and origin as the torticollis itself.
In reference to this communication, the following remarks were offered by Professor Brissaud:
It is true of all forms of functional hyperkinesis, that the indefinitely prolonged repet.i.tion of the same act leads finally not merely to muscular hypertrophy, but to a ceaseless over-activity of contraction in all the muscles affected. That this hypertrophy and hyperexcitability depend on some organic central lesion is not the necessary sequel. A purely functional exasperation may entail visible augmentation of movement, the cause of which is not central, but lies in the external manifestation of muscular over-activity.
The antagonistic gesture is, in some instances, contemporaneous with the wryneck, although more usually it is not in evidence until months or years after the distortion has become inveterate.